1813 01 REUMA3 Editoriale - ME/CFS Australia

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64 R. Casale et al.are more or less associated in almost all FM patients.It is not surprising that many patients experienceinterpersonal distress and behavioral deficits.Since CBT has been shown to be particularly effectivein distress and behavior disorders, it is logicalto apply CBT methods to FM. This approachassumes that a patient can be helped significantlyby addressing the many non-pain aspects of FM.A growing literature describes CBT treatment ofFM and has been addressed by meta analyses andreviews (55-59).A similar literature describes CBT approaches torelated disorders such as irritable bowel syndrome,and the concepts learned in these disorders are usefulfor the treatment of FM. The available evidencecan be divided into studies of CBT alone, CBT incombination with other pharmacological and nonpharmacologicaltherapies, the nature of CBT effects,patient subgrouping and tailoring CBT componentsto specific treatment.Data emerging from these reviews and meta-analysessuggest that such single method CBT (smCBT)treatments may be the least efficacious in terms ofmultiple outcome measures (60).Several studies of education programs and relaxationhave not demonstrated effects that persist infollow up evaluations. Improved results have beenobtained with multiple method CBT (mmCBT),which can include a number of components suchas cognitive restructuring, pain-coping, problemsolving, goal setting, increasing activity levels, pacing,stress management, and adjustment of painmedications in addition to education and relaxation(60, 61).The effectiveness of this approach was demonstratedin a study in which two groups received“standard” care of pharmacological therapy andexercise instruction, and one of these groups receiveda minimal package of six, one-hour groupsessions of CBT that focused on improving function.At one year, twice the number of patients receivingstandard care plus CBT reported significantimprovement in comparison to the group receivingstandard care only. At two years most patients continuedto report benefits.The principle that mmCBT is superior to smCBTcan be extended to multi-dimensional therapy inwhich mmCBT is paired with other traditional therapies.The two most common are pharmacological treatmentand exercise therapy (see this chapter). Mostreviews have discussed the positive effects of drugsassociated with various form of CBT. One issue isthat the efficacy is coupled with the short-term effectsof these drugs such that improvements maybe lost if the drug is discontinued.Many reviews of CBT for fibromyalgia concludethat the effects are modest. It is important to notethat this is true for all treatments of FMS, includingthe new generation of pharmacological agents.The fact that only one-third of participants respondto an active therapy is a challenge for the developmentof future treatments.It also raises interesting questions such as whetherthere is a small responder group that responds toany form of treatment, or a broader group, subsetsof which respond to different treatments. MmCBTtargets significant components of FM and relateddisorders, enjoys superior compliance in comparisonto exercise, and results in positive effects thatpersist after treatment.COMPLE<strong>ME</strong>NTARY AND ALTERNATIVETREAT<strong>ME</strong>NTSAs many as 87% of the general population of tertiarycare patients have tried at least one complementaryand alternative treatment (62) (Table II).Terms such as non-conventional, complementaryand alternative treatments encompass all therapeu-Table II - Use of complementary and alternative medical treatmentsat a tertiary care center (62).Techniques and unconventional N° patients (289)treatments %Physical exercises 48Prayer 45Massage 44Chiropractics 37Weight control 20Relaxation techniques 17Aromatherapy 15Music therapy 12Acupuncture 11Counseling & therapeutic groups 11Homeopathy 10Acupressure 10Magneto therapy 9Plantar reflexology 9Pranotherapy 8Biofeedback 8Therapeutic painting 5Others 8Patients using at least one of the listed therapies 87
Non pharmacological treatments in fibromyalgia 65tic and healing techniques that are not recognizedby the scientific community due to lack of pathophysiologicalevidence and mechanisms of actionthat are able to support their supposed efficacy. Allof the treatments cited below are popular with patientsand available (with payment) on several siteson the web; our search terms simply matched thetreatment type with “fibromyalgia”.Five of these are considered complementary or alternativetreatments that are more or less openlyused in FM:a) complete theoretical systems such as homeopathy,naturopathy and anthroposophy, traditionalChinese medicine, and ayurvedic medicine;b) body-mind techniques;c) nutriceutics;d) physical manipulation;e) energetic medicine encompassing pranotherapy,reiki, and healing touch.On a recent American survey (62) the most popularalternative treatments included physical exercise(48%), prayer (45%), massage (44%), and chiropractics(37%). Along with these treatments 83%of these patients use at least one vitamin and 52%use some sort of food supplementation.Complete therapeutic systemsAmong complete therapeutic systems, homeopathyis used the most. Its efficacy in FM, as for almostof its clinical application, has never been demonstratedin clinically controlled trials (63).Ayurvedic, anthroposophy and traditional Chinesemedicine as well as homeopathy are based on principlesthat are alien to Western biology and too farfrom the writer’s competence to be reasonably andfully reported here.Body-mind techniquesThis definition encompasses those techniques thatare used to improve mental control over bodilyfunctions.Some of them have been accepted already and usedin the context of traditional Western medicine suchas behavioural and cognitive therapies, supportgroups, and music therapy in its broader meaning,while others are still outside official medicine suchas meditation, therapeutic prayer, and mentallydrivenhealing techniques.Although not considered in this review, it is worthnoting the interesting results obtained by thesebody-mind techniques: they seem to be able to diminishthe number and the pain intensity of tenderpoints, and they can improve depression, anxietyand physical performance for over two years (64).Apparently, similar results have been obtained withmeditation techniques (65).Some clinical benefits have been obtained in a therapy-resistantgroup of FM patients by means ofhypnosis (66).Nutriceutics and dietary supplementationAs many as 52% of FM patients use some form ofalimentary supplementation including vitamins C(35%), E (31%), and B complex (25%) and Magnesium(29%).Green tea (24%) is popular as an antioxidant;weight control programs (20%) are also popular.Some alimentary supplements have demonstratedsome utility in reducing pain intensity and fatiguesuch as methionin (67-69) and magnesium (70, 71),while others did not show any improvement (72).Moreover, there are various other nutraceutics thatclaim some success in controlling FM-relatedsymptoms such as sleep disturbance and early sensationof fatigue.Unfortunately, as for almost all of the treatments reportedin this section, controlled studies are lacking.Some benefits have been claimed using melatonin(73), hypericum perforatum (St. John’s wort) anddietary control (74).Physical manipulationChiropratics and other forms of manipulationbased on mobilization or even manipulation ofbody segments like manual medical techniques(Meigne) and all forms of non medical massage. Itseems that the chiropractic approach is useful in thetreatment of FM.One study compared FM patients who experienced4 weeks of treatment to patients on a wait list andregistered a temporary decrease in cervical andlumbar pain in the treated group. These patientswere also taking medication (75).CONCLUSIONSFM patients frequently use alternative therapies,strongly indicating their dissatisfaction with traditionalmedical therapies as well as the substantialineffectiveness of these traditional therapies, especiallypharmacological treatment.At present, pharmacological treatments for FMShave a rather discouraging ratio poor symptom con-
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